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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NCT FILL IN <br /> File writ; DWR w'`dELi, CONIPLETILON REPORT <br /> PageJam,,of L 13ejer to Ii7strelciinn Pamdrhiet STATE WELL NO.ISTATiON NC. <br /> Ovvner's Well No. No. 749434 C11 I 1 ❑ <br /> Date Work Began -3-7-6: Ended -�� "�i° LATITUDE LONGITUDE <br /> Lrcal Pertni.t AMIV.V liu/i h <br /> "FrF„rR, , APN1TRSfOTHER <br /> Permit l��o.—DOLL at f' PeT-tnit Date �"' �:, <br /> GEOLOGIC LOG 4VEL 0W\ER <br /> ORIENTATION (� t VERTICAL HORI ONTAL „ANGLE ? �[ <br /> DRILLING —(SP'eCIFV} 1\ILM A / <br /> DEPTH FROM METHOD PTH FLUID ..�Qailii n;Acldr"es`s. Qr <br /> SURFACE DESCRIPT ON <br /> Fy. to Ft. Describe material, grain Siwe, colnr, etc.. cI?����; ; L ` j STATE ZIP <br /> .3 �A <br /> )!'RL <br /> ' I L <br /> OCAT ON <br /> See _AddroRc; <br /> ` I •r"' .Gouiitv'' <br /> Ad?N Book Pave Parcel <br /> TOW"rislnP','. Range Section <br /> " ` Latittade I NORTH Longitude I I WEST <br /> DEG. MIN' • SEC, PEG. ru11N, SEC. <br /> LOCATION SKETCH AAAAAA.0 IVITY (.:L) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> — Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> 1 t <br /> Under"GEOLOGIC LOG') <br /> f PLANNED USES I <br /> WATER SUPPLY <br /> I I Domeslie _ Public <br /> >— Irrigation _ Industrial <br /> ` 3 W MONITORING <br /> I I <br /> TEST WELL_ <br /> I CATHODIC PROTECTION <br /> I I HEAT EXCHANGE <br /> I 3 <br /> DIRECT PUSH_ <br /> I INJECTION <br /> VAPOR EXTRACTION <br />' I I <br /> SPARGING <br /> I I SOUTH <br /> 121tr.stmfe or Describe Distance of Well font Roods:,Brlildinos, REMEDIATION <br /> I I Fences,Rivers,etc.and atinch n map.tine odditinnnl(>dPer f OTHER(SPECIFY) <br /> necessary.PLEASE BF.ACCURATE '&COAf M <br /> I I <br /> PATER LEVEL & YIELD OF COINIPLETED WELL <br /> I I DEPTH TO FIRST WATER� (Ft.) BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I I <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE_ I <br /> TOTAL DEPTH OF BORING S (FeE) yam. TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> , <br /> TOTAL DEPTH OF COMP'LETED WELL � I"(Feet} *May not be rept es-mtative of a wells long-tern yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(2L) FROM SURFACE TYPE <br /> DIA. r ¢ - MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE• BEN <br /> (Inches) ¢ � J GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. i0 Ft. L» -� (inches) THICKNESS <br /> (inches) Ft. to R. (TYPE/SIZE) <br /> IT w <br /> I 4 <br /> I I <br /> I I <br /> I ! I <br /> FTACITMENTS (zL) CERTIFICATION STATEMENT <br /> i, the undersigned, certify that thisrepA "p rt}s complete and accurate to the best of my knowledge and belief, <br /> Geologic Log <br /> Well <br /> Construction Diagram NAME `I r' +' �fir' <br /> (PERSON, FI I1,­OR 1 (TYPED OR INTER) <br /> Geophysical Log{S) `A <br /> oillWater Chemical Analyses �,2JD Qet ��#* U P, 5 101 1l� <br /> ADDRESS CITY STATE ) ZIP Other q W4161 <br /> � _;rA77ACN ADD,'TlONAL INFORM T10Ar, fF!T EXl575. Signed � 1 <br /> WELL DRIlLER1AOTHORlZ EPRESENTATIVE DATE SIGNED C-57 LICENSE 4011 R <br /> owl" Iss RFv It-q-, IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />